The professional agenda and its effect on the implementation of telemedicine among primary care physicians: A qualitative study

Abstract

Introduction

Studies show that physicians’ attitudes are a major influential factor in the degree of implementation of telemedicine and that most of them identify much more opportunities in this type of visit than risks. These findings do not explain the observed decrease in the use of telemedicine in primary care with the decline of the COVID-19 pandemic. The aim of our study was to understand the gap between the attitudes that primary care physicians declare towards telemedicine and the extent to which they use it in practice.

Methods

A qualitative research using a semi-structured phone interview with 33 primary care physicians experienced in telemedicine from Leumit Health Services, a health fund in Israel. A qualitative thematic analysis method was used to extract the main themes from all interviews, and descriptive statistical tests were used to analyze the demographic variables.

Results

The attitude of the physicians depended on the perception of their professional identity and their sense of control over telemedicine implementation. The more established their professional identity and the stronger the support from the organization in the technology integration, the more positive the physician's attitude towards this type of visit.

Discussion

Healthcare organizations that wish to improve the use of telemedicine in primary care should understand that this is more than just the implementation of new technology: they must find a way to properly support the profound change that doctors must undergo when defining their new role and professional status.

Keywords

Telemedicine implementation primary care physicians professional identity

Introduction

While telemedicine visits (by telephone or video) have been available in primary care medicine for the past 20–30 years, their use has expanded rapidly during the COVID-19 pandemic.¹ Healthcare organizations have invested many resources in accelerated assimilation during the pandemic. The basic premise was that this process should have happened anyway, in light of the strong evidence of remote care's benefit on the healthcare system's usefulness,^1–5 and its ability to improve access to healthcare,³ to reduce the risk of cross-contamination,³ and to improve the efficiency of healthcare delivery.⁴ Surprisingly, a significant decrease in usage was observed in many countries, with a decline in infection rates,^6–10 enhancing the need to discuss the challenges and opportunities for sustaining telehealth beyond the COVID-19 pandemic.^4,11

Many studies have dealt with the characterization of the barriers to a successful implementation of telemedicine visits in primary care medicine (family medicine and pediatrics) and raised a variety of options, most of which have become less relevant as time has passed. For example, the technical or organizational barriers related to policies, payment, and management methods were removed gradually as telemedicine developed.

Also, patient acceptance of the modality was initially low and changed as time passed.^12–15 Now, there is evidence of a significant improvement in digital literacy in many populations.^2,16,17

The willingness of physicians to adopt the technology was identified as one of the main barriers,^2,6,8,18,19 and a strong association was found between the physicians’ approach to telemedicine and the extent of its use.^20,21 Barriers identified before the pandemic, or immediately at its beginning, included fear of harming the quality of care, technical challenges, fear of violating patient confidentiality, fear of inability to ensure the same quality standard of a frontal visit, and fear of harming the doctor–patient relationship.^22–27 Some previous studies show that after gaining experience, most of the barriers have been reduced.^28–30 Recent studies indicate that most primary care physicians (PCPs) point out different types of opportunities that the use of telemedicine allows,^12,31,32 and they understand how the addition of technology can improve the quality of care.^29,33–36

Assuming that doctors’ willingness to adopt telemedicine significantly influences the degree of its use, we must understand the gap between the doctors’ awareness that telemedicine can improve treatment and its low usage, despite accumulated experience. Understanding this gap is critical to halt the continued decline in the use of telemedicine in order to derive the expected benefits from the large investment that has already been made in the assimilation of the technology.

This study was carried out in Leumit Health Services (LHS), one of the four health funds in Israel, providing service to 712,000 insured persons throughout the country. LHS implemented telemedicine meetings with the PCP at the end of 2018. Subject to the Israel Ministry of Health guidelines, implementation was gradual but, like other healthcare systems, gained momentum when the COVID-19 pandemic broke out. During the pandemic, there was a twofold increase in video appointments and a threefold increase in telephone appointments. However, like in other places,^6–10 such visits decreased significantly as COVID-19 receded.

The aim of our study was as follows:

To explore the key factors that influence the attitudes toward telemedicine of the PCPs experienced in using it.

To evaluate the influence of the attitudes and experience gained on the willingness to use the technology.

Methods

The study design was cross-sectional based on the qualitative approach. Data were collected using a semi-structured phone interview.

Study population. PCPs who work at LHS and provide ongoing and regular care to the patient population associated with their clinic, who used video and/or telephone visits for at least 3 months until the start of the study. Doctors who joined telemedicine but, due to technical problems, were unable to provide the service were not included in the study.

Sampling and sampling method. Thirty-three PCPs of a purposive sample who performed at least 20% of their visits using telemedicine sessions and agreed to participate in the study were interviewed. The sample represented the distribution of occupational areas, gender, sectoral, and geographical spreading of the entire population of PCPs in the fund. All participants were asked and expressed their informed consent to participate in the study before the start of the interview.

Study period. April–July 2021.

Research tools. We conducted semi-structured telephone interviews. The duration of each interview was 30–40 min. The interviews were conducted by three research assistants who underwent appropriate training and used the same interview guidelines. The conversations were audio-recorded, transcribed verbatim, and then uploaded into an Excel form.

The interview questions comprised demographic information about the interviewees and their attitudes regarding the risks and opportunities of using video and telephone in telemedicine meetings.

Data analysis. A qualitative thematic analysis method was conducted according to the Braun & Clarke guidelines.³⁷

The transcripts of the interviews were read repeatedly by two researchers: one an expert family physician and the other an expert in behavioral sciences, to generate codes that were then aggregated into sub-categories and categories (Figure 1). Differences in coding were resolved by consensual dialogue. Afterward, a mapping analysis was constructed to depict associations between sub-categories and categories, enabling the extraction of themes. Three professional PCPs reviewed the analysis and the suggested themes to validate the themes’ naming and definitions. A total of 56 categories and sub-categories of themes were extracted from all interviews.

Figure 1.

Categories and sub-categories of themes extracted from the interviews (N = 33).

In addition, the demographic variables and the attitude of the interviewees towards the use of telemedicine were analyzed using basic descriptive statistics tests.

Results

As shown in Table 1, out of the 33 interviewees, 19 were women, and the average age was 57 years (range 35–72, SD 9.9). The average professional seniority was 29 years (range 5–48, SD 13), but only five interviewees had less than 15 years of experience.

Table 1.

The demographic characteristics of the interviewees (N = 33).

Variable	Value
Mean age, years (min-max)	56.88 (35–72) SD 10.0
% Males	42.4
% Females	56.7
% Family physicians	69.7%
% Pediatricians	30.3%
Average seniority in the profession, years (min-max)	29.6 (5.0–48.0) SD 12.9
% Graduates of studies in Eastern Europe	57.6%
% Graduates of studies in Israel	30.3%
% Graduates of studies in Western Europe	12.1%

Most participants (69.7%) were family physicians, and about a third (30.3%) were pediatricians. 30.3% studied medicine in Israel, and 57.6% of the others studied in East European countries and the former Soviet Union.

Table 2 shows the main themes that emerged in the interviews concerning the questions explaining the willingness to adopt telemedicine visits. The themes are divided into four main topics, generally referring to two aspects: the definition of the professional identity and the sense of involvement or control in the technology assimilation. Each topic is divided into the sub-topics included in it. The findings and analysis of each sub-topic are presented, and quotations are given for illustration, next to them.

Table 2.

The main themes, their analysis, and quotes.

Topics and Sub-Topics		Analysis	Quotes
Professional identity	Improving the treatment of acute conditions	Physicians who support the incorporation of telemedicine at work perceive the technology as an add-on that allows the physician's work to be streamlined and as a means to increase treatment. The improvement can be in acute cases, by conducting initial questioning and making decisions that will advance the treatment, or in chronic patients by ameliorating the quality of follow-up, improving the ability to initiate and enhance responsiveness, and detecting earlier a lack of balance.	“There was a patient that had changes in the facial skin. I saw it by video, gave her my opinion, and saved her a visit to the clinic….”
	Improving the treatment of acute conditions		“In all cases, you can arrange a telemedicine visit if there is a reason for a visit. I don’t mean cases of fainting, or a bad injury, just a regular visit to the clinic. In my opinion, you have to start with telemedicine, and if necessary, the doctor and the patient fix a physical meeting. There is no need to come to the clinic if it is not urgent.”
	Improving the treatment of chronic conditions		“The video helps to localize pain; you can see your patient's situation if you have not seen him for a long time. A few days ago, I had an elderly female patient by video, and I could see that her medical situation deteriorated.”
	Improving the treatment of chronic conditions		“If you have to give a prescription, it is OK…” “The video is good to see a wound,” “You can ask the patient to move the hand…,” “if somebody wants to consult with me…,” “it is good for everything that can be seen and is not complicated,” “it suits chronic and old patients.”
	The fear of making a mistake	Opponents are more concerned with the fear of using this technology. This is not a fear associated with using an unfamiliar technology but rather a suspicion and distrust in its ability to be accurate for medical diagnosis. The concern is even more substantial when the physicians think they will not have support from the organization and may pay a personal price for a misdiagnosis.	“The resolution is not good enough…it suits the work of a psychiatrist but not a family physician.”
			“I would not assume responsibility for a diagnosis only through telemedicine during routine times without corona. During corona, it can help very much to avoid meetings.”
			“It is frightening to make medical mistakes; the responsibility is frightening; everyone wants to cover himself.”
	Experience gives confidence	The wider the doctor's experience, the stronger his confidence in reaching a diagnosis and his support for integrating telemedicine into his work. Those who do not have enough clinical experience, or are unsure of their expertise and abilities, will prefer a physical encounter with patients, fearing that a remote meeting will not allow for an accurate and satisfactory diagnosis.	“The problem is not learning. Somebody that does not know how to use the computer should learn…I have experience - it was easy to identify jaundice over the video.”
			“I think that the platform is suitable for experienced doctors. If I had been a less experienced doctor, getting the feeling over the phone would have been more difficult. It is problematic for early-stage doctors. I feel sorry for young doctors whose work is mostly virtual.”
			“I feel sorry for inexperienced doctors that must diagnose through the computer.”
	The professional identity of the physician and its relation with the traditional content of a medical appointment	Some physicians define quality treatment as a treatment that enables direct physical contact with the patient. Remote examination, which is inconsistent with the examination method accepted by them, is perceived as significantly inferior, violating the professional foundation of their work, and, therefore, as a significant drawback.	“The doctor's role, to diagnose and treat, cannot be done without a physical meeting.”
			“The profession is based on examinations; you cannot diagnose by telemedicine.”
			“The medical profession is based on examining the patient. You must examine the patient; if he shows you a radiograph, it is not enough because you must touch to feel the tissues. Nothing can exchange for a doctor's checkup. If a patient tells me his back hurts him, there is no way I can diagnose through the camera.”
	Contempt for the meeting and reduction of the doctor's role	In the doctors’ experience, the burden of investing in the technical process of starting the digital meeting applies only to them. It thus is wasted time that does not contribute to the patient's health. On the other hand, the patient makes appointments more easily than before and takes advantage of this to discuss administrative issues with the physician or consult on matters they would have previously dealt with on their own. The gap between the doctor's investment in time and his decreased perception of the visit's significance changes the doctor's traditional place. It raises questions about how his professional vocation is reflected in a remote meeting.	“The doctor feels his professionalism declines when transferred to this platform. Sometimes I feel like a telephone operator; the person is unavailable, and I wait. There is much involvement with the procedural aspects, which is not our profession. It lowers the quality of the meeting very much.”
	Contempt for the meeting and reduction of the doctor's role		“It does not matter. In our profession, a physical examination is what has to be done. Telemedicine is good, but only for administrative issues. In any case, physical examination is essential.”
The relationship with the patient's discomfort upon exposure	Exposure to the patient's environment—improving understanding of the patient's context	Some doctors say telemedicine allows them to expand the therapeutic space, bridge the distance, and get closer to the patient. Proximity allows meeting even those who cannot be reached and improves the overall understanding of the medical condition by allowing the physician to connect to the context and environment in which the patient lives.	“It is more personal; you see the patient's face, give him attention and understand his surroundings. Particularly during the corona, when many people needed help and advice and could not come to the clinic.” For example, I had a 90-year-old woman who had something in the back of her neck but did not want to leave her home and come to the clinic. We did a video visit.
			“I interact more with the patient; I can see his facial expression, surroundings, and the children who do or do not join the conversation. If it is an elderly person, I sometimes see children that help, and I see the conditions where the patient lives.”
			“This way, I see the home; I also see with whom I speak; they allow me to enter their home and see their conditions.”
	The barrier of language	Some physicians identify barriers to communication with the patient. There are objective barriers associated with language or communication gaps and subjective barriers of the patient who feels uncomfortable being exposed to a camera. But the barrier mentioned more than others relates to the patient's setting, which can divert his attention and not allow him the concentration required or gain confidence in the recommended treatment. These physicians estimate that an effective medical session has an advantage over the traditional setting in which the patient is prepared for the session in the waiting room, enters the physician's room, and is entirely with him.	“…We started video talks one year before the corona. Sometimes Ethiopians…because there are people 50–60 years old that do not speak Hebrew, and I do not speak Ethiopian…I don’t understand a word; therefore, if children are at home…it also helps…they translate for their mother.”
	Discomfort in exposure		“Some people feel uncomfortable opening the camera…being in front of the camera.”
	The barrier to the patient's attention during the visit		“For a good quality meeting, you have to get organized ahead, but there are unexpected constraints at home, the phone rings, and so on, and that bothers.”
The relationship with the staff and the management of the agenda at the clinic	More efficient load management	Some doctors find remote visits short and, therefore, more effective. These physicians benefit from the efficacy that telemedicine integration allows in load management.	“It saves time for the doctor and the patient; the telemedicine meeting is shorter than the frontal visit because they know time is limited….”
	More efficient load management	Physicians who identified telemedicine as promoting their work expressed a sense of control and took a more proactive approach. This approach is reflected in greater involvement in selecting the relative share and timing of telemedicine sessions and greater influence on the patient's choice of type of visit to suit their needs.	“From the visiting time point of view, the best is at the beginning of the working day. Later in the middle or the end of the working day, there are delays due to long lines and frontal delays or urgent issues.”
	The difficulty in managing combined appointment scheduling—remote and frontal	Doctors that perceive telemedicine as an addition feel that the overload is intensified. It has been argued that telemedicine sessions are set on a tight schedule even though they require additional time to operate the technical interface. Also, they have trouble scheduling appointments intermittently incorporating frontal and remote sessions, especially when elderly patients or those with an urgent problem await them.	“…It is a problem that by us patients enter without knocking at the door, and then they yell why don’t I see them, and it is difficult to explain to them what I am doing. We have to think about the logistics to avoid these cases.”
			“I am on the video, and people are waiting for me outside. They see me alone in the room, nobody comes in, and they are annoyed.….”
			“Patients enter my room in the middle of a telemedicine call….”
	Ease of receiving the service is a factor in undervaluing the doctor's time	The feeling that the doctor invests more in the meeting than the patient produces a sense of overload.	“…Treatments in the clinic are always faster, getting the patient's medical records. People often join telemedicine calls for unimportant issues; phone calls are often about nonsense. Often, people ask for a video meeting for something irrelevant and don’t take it seriously because they do not have to come to the clinic.”
			“Several problems cause it to be ineffective. 1-it wastes time due to technical problems which have not yet been solved. 2–90% join unnecessarily; they have the option to press the key, but there is no need, and it is unimportant.”
	The gap between the doctor's investment and the rest of the staff's investment	The feeling of overload is intensified when the doctor does not receive the support he expects from the staff in the clinic.	“Video does not work for me…I contacted the support unit, then it started working and stopped again. Once, they told me I did not know how to use it, but that was not true. It saddens me that I do not get help. I have been working here for five years; they are progressing much, but not so much with the Zoom…”
The technical challenge	A doctor who receives more support is more proactive	The physician's degree of ease or investment in operating the technology versus the organization's investment in providing technical support to the physician affects the attitude toward the technology. Support has been found to help implement the use of technology. It is essential to combine technical and administrative support. A relationship was found between the degree of willingness to adopt telemedicine and the feeling of receiving support from the organization.	“I did not have technical problems with the video. If the computer worked, I did not meet obstacles. There is technical support in case of problems. The use of telemedicine calls should be easy whenever convenient for the patient. He should be free to ask for a telemedicine call during the physician's working hours without limiting the number of telemedicine calls. I want them to ask for telemedicine calls whenever and as often as they want.”

	The gap between the doctor's investment and the organization's investment	A negative relationship was found between the degree of willingness to adopt telemedicine and the feeling of lack of support from the organization.	“Video does not work for me… I called support…always the same problem. One day it works, and the next, it does not work… I report that I failed to connect due to technical problems. And I call with the regular phone to ask what the problem is.”
			“90% of the time, I attend by telemedicine, and then I also invite for treatment in the clinic….”

The findings presented in Table 2 illustrate that, from the professional point of view, the interviewees were divided into those who saw telemedicine as an opportunity to expand the therapeutic setting, respond more quickly to acute situations, and make treatment accessible to a wider range of chronic patients. The physicians who attributed to telemedicine a positive effect on their professional status were usually the more experienced doctors who, apparently, have a defined personal professional identity. These physicians gained successful experience with telemedicine visits. They learned how to manage their work schedule in a way that will help them take advantage of the implementation of telemedicine to manage their workload. They also felt confident to harness the clinic staff to improve how visits are organized and get support when needed.

In contrast, other doctors experienced telemedicine as breaking the traditional treatment framework, threatening their ability to maintain their professional status. These doctors attributed a critical value to the physical examination in the doctor's room, without which they believed that the contribution to the patient's health could not be sufficient. These doctors also attached great importance to the traditional setting of the visit to the doctor's clinic and saw the transition to a remote visit as a violation of the balance in the relationship with the patient. They demonstrated the violation of the balance through the additional effort that the doctor invests in a remote visit when less effort is required for the patient compared to a frontal visit. The more the doctor experiences technical malfunctions and the less support he experiences from the technical staff or the staff at the clinic, the greater the perceived gap in the relationship and, at the same time, the stronger the feeling that the patient too easily makes appointments for situations of low clinical importance. For those who felt the need for more support from the organization, there was also a greater fear that they would not receive support if their professional decisions were wrong. Therefore, their tendency to invite patients for a physical examination at the clinic after the telemedicine visit was greater. For them, also, telemedicine created an additional burden.

The effect of the supporters’ and opponents’ positions on the actual conduct can be examined according to the elements of the Tripartite Model. This model defines attitude as a prolonged response to an abstract or a tangible object. According to the model, each attitude is based on three dimensions: cognition, behavior, and affect. Although the three dimensions are usually related, one can experience conflict between them.^38,39 Table 3 presents examples of negative versus positive affects (feelings), cognitions (thoughts and beliefs), and behavior intentions (the actual use of telemedicine visits) of the PCPs who were interviewed.

Table 3.

Examples of negative vs. positive attitudes toward telemedicine.

	Positive attitudes	Negative attitudes
Cognition	- “It has a very positive aspect. During COVID-19, there were many phone calls, but with video, investing more in the quality of care is possible. It is good for the patient and the physician alike. The patient can see his doctor, and it gives him confidence.” - “You can keep eye contact.”	- “Harassment to both the patient and the physician. I estimate that 60% of those who contact via telemedicine must visit the clinic. If the complaint concerns back or stomach aches… I can`t check it… If the patient wants to discuss administrative issues, it is OK… but nothing more.” - “Regarding communication… the software has many problems. It complicates the meeting and the whole working day”….
Affect	“Patients are satisfied with telecare. They see me, and I can observe them. I have eye contact, and I like it.”	- “This platform is not convenient….” - “There are physicians that don’t use telemedicine…maybe they fear errors… maybe out of lack of confidence….” - “I am afraid to miss something.”
Behavior	- “Telemedicine is integrated daily. Today, for instance, I have four meetings; I video chat from 12:30….” - “I have telemedicine visits daily, and I manage to answer all calls.” - “It has become an integral part of my workday. It is part of my schedule.”	- “The video doesn’t operate well. I call technical support … every day, the same problem. It disconnects… I call the patient and always say that I had technical problems”… - “Ninety percent of the time, I invite the patient to the clinic following the telemedicine visit”…

A manifested content analysis of the answers indicated two different perspectives: nearly 50% (17 of the interviewees) had positive attitudes towards the use of telemedicine while the other half (16 participants) expressed their dissatisfaction with the modality.

Among the positive feelings, we detected a sense of confidence, satisfaction, and even a feeling of pride in the ability to diagnose remotely. In contrast, those with a negative attitude felt that telemedicine is a cumbersome, disruptive, and even stressful addition to the workday.

As described in Figure 2, there is a circular process of attitude—experience—behavior, and vice versa.

Figure 2.

The telemedicine feedback loop: how the use and attitudes toward telemedicine are reinforced.

A positive association was found between attitudes toward integrating telemedicine into work and the telemedicine experience.

Those with positive experience had positive attitudes towards the use of telemedicine. They declared that they manage to practice telemedicine efficiency, that they have good experience with the technology, and find it beneficial. They knew how to recruit help from the staff and the management when needed, and manifested a proactive approach using telemedicine. This successful implementation intensified the positive experience and attitudes and contributed to the continued successful utilization of this technology and further incorporating telemedicine into their work. In contrary, a negative experience was associated with a no-choice attitude and a feeling of “forced-on-me” and thus unwillingness to use telemedicine on a regular basis. These participants expressed their dissatisfaction with the modality, emphasized the disadvantages that they had experienced such as impaired interaction with patients, inadequate diagnosis due to the remote process, technological malfunctions, etc. These PCP's said that they don’t find telemedicine as a good or even valid mean of communication with patients, that it has limited or low efficiency, and some mentioned that they try to avoid telemedicine visits if they can. Thus, if they have to practice it according to the clinique policy, they do it unwillingly.

Discussion

Many studies show that doctors recognize many opportunities in the implementation of telemedicine visits, yet their willingness to adopt the technology is significantly lower than expected.^{2,6,10,12,18–20,29,31–35}

This study aimed to understand the gaps between the theoretical positions and the degree of adoption by PCPs in LHS after they gained experience with telemedicine. We used a qualitative research method to uncover barriers related to feelings, values, and needs and to identify information that the quantitative studies carried out so far may not have recognized.

Our study benefited from the controlled setting, as organizational telemedicine policies and rewards for usage remained consistent throughout the research period. This differs from other studies conducted during the pandemic, making it difficult to isolate the effects of policy changes on physicians’ attitudes.^{2,24,25,29,30,34,40}

Our findings indicate that physicians’ attitudes represent professional, self, and role perception dilemmas.

First and foremost, PCPs base their support for the implementation of telemedicine according to the contribution they estimate it will have to the health value when treating the patient. The degree of contribution is assessed differently by individual doctors and is influenced mainly by professional experience, seniority, and familiarity with telemedicine. As previously reported,⁴¹ more experienced PCPs feel confident to try new communication technologies and challenge traditional examining methods. In contrast, PCPs with lower professional confidence prefer work methods they are familiar with. We found that this attitude has a circular effect on the willingness to adopt telemedicine: PCPs with a positive attitude tend to create opportunities and identify the type of encounters where telemedicine can add value. The more comprehensive the doctor's experience with telemedicine, the stronger his confidence in reaching a diagnosis and his support for integrating telemedicine into his work. In contrast, PCPs who prefer to work in the traditional and familiar way show passivity in managing the mix of visit types, letting the patient determine the kind of encounter. Then, they express more frustration because more visits are scheduled to address administrative issues with a lower therapeutic value. These doctors will also prefer to complete telemedicine visits with the patient's appointment for a traditional face-to-face examination at the clinic. As a result, they will gain less experience in remote examination and will lack confidence in their ability to achieve an accurate and satisfactory diagnosis by telemedicine.

A negative correlation was also found between the degree of willingness to adopt telemedicine and the feeling of lack of support from the organization. These feelings relate to the doctor's more basic perceptions of his place in the team, the degree to which he feels that the organization considers his needs and the degree to which he feels involved in decisions about providing the service. The more the PCP thinks that the organization supports him, the greater his willingness to use telemedicine. On the other hand, PCPs who, in their opinion, face the new technology alone describe an experience of increased workload and frustration. They consider their investment in the visit's success as more significant than the patient's and greater than the organization's investment.

These processes demonstrate a feedback loop between experience and attitudes, which can result in an acceleration or deceleration of telemedicine usage. According to Kolb's experiential learning cycle,⁴² which is also relevant for the adoption of new technologies, knowledge is generated through the transformation of experience. The learning cycle consists of four stages: concrete experience, reflective observation, abstract conceptualization, and active experimentation. In the concrete experience stage, the learner engages in a task or activity. In the reflective observation stage, the learner reflects on their experience. In the abstract conceptualization stage, the learner formulates generalizations and conceptualizations based on their experience. Finally, in the active experimentation stage, the learner tests the implications of their concepts in new situations. It is important to note that these stages are part of a cyclical iterative process: the learner goes through the four stages multiple times, progressively enhancing their performance and knowledge.

According to this theory, positive experiences can foster positive attitudes, which, in turn, can lead to increased telemedicine usage. Conversely, negative experiences can result in negative attitudes, leading to decreased telemedicine usage.

Another major professional issue deals with the relationship between the doctor and the patient and the balance required to generate the trust that should lead to the patient's motivation for treatment. In this context, the change in the meeting setting produces a shift in the balance of the relationship. The therapeutic space seems to become less secure because, in contrast to the conventional meeting, the patient is the one that chooses where to be, to what extent he is available, and who else will attend the session. With telemedicine, patients may take advantage of the ease of scheduling appointments for administrative issues or minor medical questions that previously would not have concerned them. The PCPs feel their time and ability are “wasted” in favor of situations that bring lower health opportunities. Here also, PCPs with more vast experience or high self-professional confidence are less threatened and are more active in guiding patients to choose the appropriate type of visit for their medical needs.

Three major shortcomings of the study should be considered. The study describes physicians’ attitudes from one health organization in Israel, and it is unknown to what extent this experience represents all physicians. However, similar conclusions from other studies^8,9 indicate that the positions are based on general perceptions rather than how the service is built in a specific organization. Another drawback is the social desirability bias because interviews were in person thus not anonymous to the research assistants responsible for conducting the interviews. The fact that the weight of the positive and negative attitudes was similar allows the assumption that this bias did not have a significant effect.

Lastly, our findings regarding the association between the PCP's attitudes and their tendency to use telemedicine are based on their own testimony during the interview. We did not examine the association between the attitudes of PCPs and their actual usage of telemedicine during the decline of the epidemic, in practical terms. This limitation arose from the research protocol and informed consent procedures of our study that required keeping the identities of the interviewees confidential and thus the names of the participants were held only by the research assistants and were not disclosed to the researchers themselves. Since the general trend of telemedicine usage by primary care doctors in LHS is consistent with the literature, and our sample is representative of the PCP population in LHS, it is reasonable to assume that it is also represented the doctors who were interviewed. However, it is highly recommended in future researches to examine how PCP's attitudes predict their actual use of telemedicine as part of their routine practice via a longitudinal study design and objective organizational records.

To the best of our knowledge, this is the most comprehensive qualitative study on the attitudes of PCPs who have experienced telemedicine aiming to understand the gap between physicians’ attitudes towards telemedicine and their actual use of it in practice.

There is growing evidence that telemedicine is a safe and effective way to deliver healthcare, and that it has the potential to improve patient outcomes^1,11 and therefore should be encouraged.

Our research shows that implementing telemedicine deals not just with changing technologies and how the therapeutic job is being done, but with changing the perceptions of the physicians’ professional identity and role description. It is not merely a technological change but an organizational and professional cultural change, requiring adopting new values and behavioral norms. Policymakers are advised to act by the recommendation of David Rogers^43,44 and understand that the assimilation of telemedicine is not only the assimilation of new technology but is concerned with strategy, leadership, and adaptation of corporate culture.

We also recommend policymakers and others who try to implement telemedicine change, to take into account the telemedicine feedback loop between experience and attitude. This feedback loop can be a powerful force, and it's important to consider it when trying to increase telemedicine usage. By ensuring that PCP's will gain positive experiences with telemedicine by organizational, administrative, and technical support, and by adequate professional and non-technical training, one can help to create a positive feedback loop that will lead to increased telemedicine usage.

Footnotes

Acknowledgments

The authors wish to express their deep gratitude to Mrs. Talma Peer RN, MPH, Director of the LHS Risk Management Department, who was among the study's initiators and contributed significantly to its construction.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics approval

The study was approved by the Leumit Health Services’ Review Board and the Ethics Committee/IRB of Shamir Medical Center (ID number 149-20-LEU, Date: 12.05.2020).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Avivit Golan Cohen

Eugene Merzon

Data availability statement

The datasets analyzed during the current study are not publicly available because they are business information but are available from the corresponding author upon reasonable request.

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